PICC nurses pulling picc lines with associated DVT/thrombus formation

Looking to find out what other picc teams do: We are currently working on a position paper for our vascular access team that involves how we handle lines with associated clot formations. We know that the majority of clot formations are non symptomatic, we also realize that the new recommendations based on 2008 ACCP physician guidelines as well as ava recommendations to leave lines in place, treat and reultrasound whenever possible, also incorporating treatment with LMWH or heparin. However, there are times when physicians would like the picc lines pulled. We have consulted with a vascular physician in our facility and we currently will pull the line once heparin or low molecular wt heparin (lovenox) is initiated prior to pulling of the picc line. The issue is that there are nurses in our department are not comfortable with pulling these lines. I am of the mindset that we are in a hospital, have access to physicians and emergency equipment, and are the ones who are the caregivers of these lines and we should also be responsible for pulling the lines when this is ordered by the MD. There are others who are afraid and feel that they would be held accountable should the patient throw a pulmonary embolism and insisist that the MD should pull the line.

I would like to know what other picc teams do and do the nurses on these teams have issue with this? Any information/feedback would be greatly appreicated.

I work in a level one trauma hospital. We have had doc's ask for these lines to be pulled, but we will usually ask them to anti-coagulate the pt first, and leave the line in if it is possible. We have had some recent success in leaving the line in and anti-coagulating the pt with heparin or Lovenox. I had a pt 2 weeks ago the had a right picc with tip termination in lower SVC that ended up with every large vein in her right upper arm and up into the axillay, thrombosed. The doc placed her on heparin for 3 days, left the picc in, and continued her on a high dose of Lovenox. The ultrasound done 5 days later showed very little to no clot formation and the picc is still in with no more complications. It is really a patient specific decision in my opinion, but there is not enough information out there to support a difinitive answer either way, and it would be a very expensive study to do from what I have looked into on the subject with the pre and post ultrasounds that would need to be done.

We work in a level 1 academic trauma center, and we are fortunate enough to have a full vascular access and PICC team. We feel that we would do a better job removing the line and caring for the site, know what to expect whether we know there is a thrombus or not, and have resources readily available to us if PE occurs. We'll also talk with care team about treating and leaving line in place.

In our center, if a CR-Thrombosis is confirmed and the patient is symptomatic, we want the physician to remove the line - if it is decided that the line needs to be removed (thrombus suspected to be infected, tip malpositionned). We do not have dedicated vascular access team that care for all lines so, all nurses may remove lines, whether the insert the catheter or not. We have decided that we want the physician to remove the line to ensure fast access to the physician if PE occurs. Physicians are not always on the unit, especially on our long-term units.

Thank you so much everyone for all the input. I agree, we should be responsible for all potential complications for central lines including DVT occurence. We do provide an informed consent in which we discuss the issue of clot formation. This will make for good conversation at our next clinical practice meeting.

Catheter-related thrombosis is not related to a specific brand of PICC or type of catheter material. It is caused by the size of the catheter being too large for the vein diameter, a rapid or traumatic insertion technique, suboptimal tip location, and numerous patient factors such as diagnosis and other hypercoagulable states. Lynn

Great conversations about clot formation. My concern is similar. Is there any literature out there talking about prevalence of clot formation the length of the line of PICC's in general. We happened to do an ultrasound post removal of a PICC and found clot pretty much length of line. Patient with no symptoms

prior to removal or after removal. If an ultrasound was not done we never would have know. Is it product related? Any info anyone has would be greatly appreciated.

There are reports of incidence of upper extremity DVT and resulting PE. The general trend is that the incidence of both is increasing, primarily due to the increasing use of CVCs. I can not remember the exact statistics but you can find it in the literature. Also, I do not remember anything specific in these studies about catheter removal. PE can and does occur at any point in the catheter dwell. The basilic and brachial veins are both deep veins at the point of insertion in the upper arm. The basilic vein is a superficial vein in the forearm but becomes a deep vein just above the AC. Brachial veins are smaller so there could be an increased risk, but do not recall having actually seen that in the literature either. Lynn

Is there any studies or statistics on a clot or portion of it breaking off during a line removal?

I have Drs who feel like they should keep a line in for fear pulling it would "break off " the clot and send it out to the lungs. I feel like Lynn in that we are removing them all the time and probably are just not aware until symptoms show up that it is there.

I have another Dr who says by the time we are aware of the dvt the thrombus has adhered to the vein wall and will not be dislodged by removal of the catheter.

Is there any difference in treatment for basilic/brachial, since one is superficial and the other deep.

Any specific findings noted on ultrasound of the dvt/thrombus that should alert us to concern; besides fully obstructing blood flow. I have never had an u.s. reading be specific and say the percentage of occlusion of the vessel, would different percentages make different treatments. Or are we basing it on symptoms?

I agree with you on the reasons why IV/VA nurses should pull these lines. I also have one other point. We know that the majority of catheter-related vein thrombosis is clinically silent. The nurse does not know that it is present, yet pulls the line anyway. I see no difference in pulling the line with a known thrombosis vs one where the presence of the thrombus is not known. Embolism is a known complication of catheters. If it happens, the nurse (and any other professioal) would be judged on the appropriate management of the situation. As you say, you are in the hospital with the right amount of equipment and other personnel for support. All professionals including nurses who have the responsibility for inserting lines must also accept the accountability for the outcome. Who pulls the line will not alter that fact. If this clot was caused by a suboptimal tip location and the nurse decided to allow it to remain in this location, then there would be liability. Even if the MD pulled the line and it could be shown that the clot was related to a decision made about tip location during insertion, the inserting nurse is still held accountable. So if they will not take responsibility for pulling lines, they should not even be inserting them. Just my opinion. Lynn